Provider Demographics
NPI:1598131906
Name:BOUDREAUX, MINDY
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 KALISTE SALOOM RD
Mailing Address - Street 2:SUITE 219
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4230
Mailing Address - Country:US
Mailing Address - Phone:337-504-4974
Mailing Address - Fax:
Practice Address - Street 1:850 KALISTE SALOOM RD
Practice Address - Street 2:SUITE 219
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4230
Practice Address - Country:US
Practice Address - Phone:337-504-4974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5554101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health